New steps reduce pneumonia rates
Over the last several years, thoracic surgeon Varun Puri, MD, MSCI, has introduced several measures to reduce the incidence of pneumonia in patients undergoing surgical removal of the esophagus or lung. Pneumonia is a major complication that can lead to longer hospital stays, additional treatment and even death.
The work is an example of T3 translational research, in which comparative effectiveness/clinical studies are translated to clinical practice.
“The incidence of pneumonia after esophagus removal varies from about 10 to 25 percent, and it’s probably the single most significant variable predicting early postoperative death,” says Puri. “In patients undergoing lung removal, the incidence is lower, in the range of 5 to 10 percent, but it still is a major complication and often leads to intensive care unit readmission and ventilation.”
In 2011, Puri and Yinin Hu, MD, then a Washington University medical student, reported improved outcomes after esophagus removal by changing the type of tube used to deliver food and medicine directly to the stomach. Instead of the conventional nasogastric tube, inserted into the stomach through the nose, they used a retrograde gastrostomy (RG) tube, inserted through the abdominal wall into the small intestine and stomach. The switch decreased the incidence of postoperative pneumonia from a range of 20-25 percent to 10-15 percent.
Puri is now reviewing data from a prospective clinical trial inves-tigating several other interventions. Participating patients, undergoing lung or esophagus removal, practiced an intensive oral hygiene regimen — brushing three times a day for a minimum of five days before surgery and applying a germ-killing chlorhexidine solution. Esophagectomy patients also could opt for use of an endotracheal tube that prevents nose and mouth secretions from pooling and entering the lungs. The results will be compared with a control group of patients who had the same surgical procedures sometime in the past three to five years.
“I think the intensive tooth brushing and oral hygiene is probably an important component of this group of interventions,” says Puri.
If results are positive, Puri hopes to further test the measures in a multicenter trial.
Section earns STS’ highest rating
The Society of Thoracic Surgeons (STS) gave Washington University thoracic surgeons at Barnes-Jewish Hospital a three-star rating for lung cancer surgical outcomes between July 2011 and June 2014. The rating, the highest possible, is based on a composite score calculated from the STS National Database.
“This is the first time they provided a composite score from the STS Database for general thoracic surgery,” says Bryan Meyers, MD, MPH, chief of the Section of General Thoracic Surgery and the Patrick and Joy Williamson Chair in Cardiothoracic Surgery. “The actual observed results were compared to the expected outcomes to grade the program.”
The surgeons scored well on other benchmarks, including for their use of minimally invasive rather than open surgery for performing lobectomy in patients with Stage I lung cancer. They chose minimally invasive surgery — widely considered safer and equally effective in controlling cancer and sampling lymph nodes — in 78.6 percent of patients, compared with an STS average of 63.7 percent.
Highlights
- Daniel Kreisel, MD, PhD, was named surgical director of the Lung Transplant Program at Barnes-Jewish Hospital in January 2015. Since joining the faculty in 2006, Kreisel has dedicated his clinical and research efforts to lung transplantation. A member of the Thoracic Immunobiology Lab, he focuses on why failure rates after lung transplantation are higher than after transplantation of other grafts. He is a member of The American Society of Clinical Investigation, a section editor for The Journal of Immunology and a standing member on the NIH Transplantation, Tumor and Tolerance Study Section. Kreisel succeeds Alec Patterson, MD, the Joseph C. Bancroft Professor of Surgery, who served as surgical director for 22 years.
- Thoracic Surgery Chief Bryan Meyers, MD, MPH, is involved in key process-improvement projects as chair of the Maintenance of Certification Committee of the American Board of Thoracic Surgery. Among the improvements: During the recertification process enabling surgeons to maintain their board certification, thoracic surgeons are being asked to focus on an important aspect of their practice and try to improve it compared with national benchmarks. The thoracic surgery board is also the first among the American Board of Medical Specialties to offer a self-paced, on-line “high stakes” recertifying exam that can be done from home or office; the exam lets surgeons learn in real-time why a chosen answer was correct or incorrect and allows them to go back and correct it. The idea is to make the exam less punitive and more of a learning process for assessing and improving knowledge. Modern software and computer cameras ensure the test-taker’s identity and spot-check exam behavior.